HIV Testing Just Got A Lot Easier: Putting ACTS into Action AETC NRC Training Exchange May 23, 2006 Donna Futterman, MD Stephen Stafford

Today’s Agenda  The Tipping Point for Routine HIV Testing  The Evolution / Intelligent Design of HIV C&T  Results from ACTS in Action  A User’s Guide to the ACTS Approach & Tools  ACTS Role Play  Questions & Discussion 2

Unfinished Business  HIV is the worst epidemic in history  40,000 new cases each year; 25-50% among youth  1 in 4 (  300,000) HIV+ Americans don’t know they’re infected  80% of young HIV+ gay and bisexual men didn’t know their status  41% of those diagnosed HIV+ were diagnosed with AIDS within one year of their positive HIV test 3

Taking Care of Business  Case finding hasn’t kept up with treatment advances  Patients overwhelmingly accept HIV testing when a provider recommends it  The mobilization for prenatal testing missed a golden opportunity to routinize screening for all, but it remains a successful model for how to proceed 4

Routine Testing: The Benefits REDUCES HIV TRANSMISSION  HIV+ people who know their status reduce high-risk sex by about 50%  Lower viral loads from ARVs also reduce Tx PROLONGS LIFE  HIV treatment can increase survival by many years and improve quality of life 5

Routine Testing: Best Practice  2003, CDC issues “Advancing HIV Prevention: New Strategies for a Changing Epidemic” calling for routine testing in communities with ≥ 1% HIV prevalence  2005, routing testing found cost/care effective in settings with ≥.05% HIV prevalence  CDC, HRSA & DOHs working toward routine testing by streamlining counseling & consent  ACTS makes provider-delivered routine testing feasible in various care settings 6

Keeping Up with the Times 1986 Environment  No effective treatment  Discrimination against those infected: MSM, IDU, immigrants & sex workers Policy  C&T regulations often written to limit testing:  mandated counseling  written consent 2006 Environment  Many effective treatments  HIV discrimination reduced & at-risk populations have changed Policy  C&T regulations remain largely unchanged:  separates C&T from routine medical care  prevention value of pre- test counseling minimal 7

Why Don’t Providers Routinely Test?  2001 qualitative research investigated HCP motivators and barriers impacting HIV testing of adolescents  Commissioned by AAP, conducted by professional qualitative research firm  Interviewed 55 Bronx-based providers and administrators in public and private settings  Key findings informed ACTS initiative 8

“Not Enough Time, Not Enough Experience, Not Aware of Risk”  Found that conventional HIV testing is: time-intensive specialized stigmatized separated from routine care 9

It’s Time for a Paradigm Shift! HIV testing has become such a huge obstacle that many providers and patients prefer to sail around it. It’s Time for a Paradigm Shift! HIV testing has become such a huge obstacle that many providers and patients prefer to sail around it. 10

The Provider Imperative: Less Referring, More Screening  YOU can help solve the solvable problem of finding the ±300K unidentified HIV+ patients  YOU can provide links to effective prevention counseling  YOU can engage HIV+ patients into early care  YOU are an essential player in the team that will meet public health HIV/AIDS goals 11

Fast Facts on ACTS ACTS is a concise, comprehensive system that makes provider-delivered HIV testing feasible in clinical care settings  Provides instruction & tools for making operational and clinical practice changes  Meets CDC and DOH testing requirements  Condenses 45-minute process to 5-10 minutes  Allows for better allocation of counseling resources 12

ACTS in ACTION Results from a Randomized Control Trial  10 Bronx clinics randomized to receive ACTS rapid counseling in late 2004  Divided into 5 ACTS Sites & 5 Control Sites  Data collected on HIV testing rates  Eligible patients included those age 15-64, non-maternity patients 13

ACTS in ACTION ACTS Sites Double HIV Testing Rates 14

Elements of the ACTS System Meeting with the HIV coordinator, clinic administrator and medical director to develop implementation plan Academic detailing session(s) to train clinic staff on ACTS ACTS manual and toolkit containing information, materials and resources for providers, clinic staff and patients 15

Laying the Foundation for ACTS with Key Staff Address Philosophical Barriers  Skepticism about patients’ HIV risk  Other health problems viewed as priority  Concerns about loss of prevention Address Logistical Barriers  Which staff will test  Documentation & consent forms  Patient flow & results follow-up  Billing issues 16

ACTS Site Prep Checklist 17

Training Staff to Utilize ACTS Academic Detailing  Provider-led training  Catered  Follow-up trainings with new staff Ongoing Support  Regular meetings with key staff to problem- solve barriers  Ongoing data reporting to all staff via meetings and newsletters 18

ACTS Materials 19

It’s All in the Manual Part I – ACTS HIV Counseling and Testing System ACTS Pocket Card Talking Points for Translating ACTS into Action Essential Forms Patient Education Part II – ACTS Backgrounders Chapter 1 – HIV Counseling: Delivering Results Chapter 2 – HIV Testing Procedures Chapter 3 – Working with Special Populations Chapter 4 – Prevention Essentials Chapter 5 – The ACTS Imperative Part III - Resources concise comprehensive 20

The Pocket Guide to ACTS 21

ACTS Talking Points 22

Forms 23

ACTS Chart Stickers 24

ACTS Update Newsletter 25

Patient HIV Info Brochures 26

The Deal 27

The “A” in ACTS 28

Transmission Basics: The Risk Continuum Concept Page 75 Talking Points Page 10 ACTS PRE Screen Page 24 Taking a Sexual and Drug Use History Page 77 Reality-Based Prevention Counseling Page 78 29

The “C” in ACTS 30

The “T” in ACTS 31

The “S” in ACTS 32

Talking Points: Delivering HIV+ Results  Give results and allow time to process Rapid Conventional  Discuss meaning of results  Provide support  Link to care  Discuss prevention  Review HIV reporting and partner notification options  Screen each name for domestic violence risk 33

Putting ACTS into ACTION: Who Benefits? Your Patients Your Practice  Do what many providers can’t / won’t do  Bill for additional counseling visit  Participate in national pilot intervention Our Community  Help us fine-tune ACTS; understand how it works  Do your part to make ACTS a model for others  Be on record as having solved this problem! Public Health 34

ACTS in ACTION Future Plans for ACTS  Continued regional & national dissemination  Presentation of ACTS at 2006 International AIDS Conference & Ryan White Clinical Care Conference in August  Expansion of ACTS to Bronx control sites in September 2006  Ongoing implementation: CDC-sponsored South Africa Youth Clinics Pediatric ER at Montefiore National Assembly on School-Based Health Care 35

Hearing ACTS in Action Alex  36 year old white male  Engaged to be married in 6 months  Visiting for routine BP check-up Keisha  40 year old African American woman  Divorced mother of 3, dating 1 man exclusively  Visiting for a vaginal infection 36

Questions & Discussion 37

Take a few moments to evaluate this presentation. Visit to quickly submit your comments 38

Contact Us / Order Materials Donna Futterman, MD Stephen Stafford Michelle Lyle, MPH Adolescent AIDS Program Children’s Hospital at Montefiore AdolescentAIDS.org